At Least One in 100 Affected by Schizophrenia

By Michelle Gardner

The National Mental Health Association (www.nmha.org) offers a fact sheet sharing what you need to know about schizophrenia, which is a serious disorder affecting how a person thinks, feels and acts. Someone with schizophrenia may have difficulty distinguishing between what is real and what is imaginary; may be unresponsive or withdrawn; and may have difficulty expressing normal emotions in social situations.

It continues to say that, contrary to public perception, schizophrenia is not a split personality or multiple personalities. The vast majority of people with the disorder are not violent and do not pose a danger to others. Schizophrenia is not caused by childhood experiences, poor parenting or lack of willpower, nor are symptoms identical for each person.

While the cause of schizophrenia is unclear, theories include: genetics (heredity), biology (the imbalance in the brain's chemistry) and possible viral infections and immune disorders. People with schizophrenia have a chemical imbalance of serotonin and dopamine, which are neurotransmitters that allow nerve cells in the brain to send messages to each other.

The Genetic Link

Stephen J. Bartels, MD, PhD, is an associate professor of psychiatry at Dartmouth Medical School in Lebanon, N.H., immediate past president of the American Association for Geriatric Psychiatry, and director of the Aging Services Research Center at the New Hampshire-Dartmouth Psychiatric Research Institute. While he agrees that the prevalence of schizophrenia in the elderly may be similar to younger age groups -- one in 100, or 1 percent -- it is hard to be sure because the epidemiological studies substantially underestimate it.

"Not only did researchers not go to long-term care facilities, but getting a reasonable diagnostic interview from someone who is older and may be paranoid is not likely to happen," says Bartels. "Schizophrenia clearly involves genetics and it has a pathophysiology to it. We know the brains of people with schizophrenia are different from normal brains. We know that some of the neurotransmitter levels are different in certain parts of the brain. We believe it is a biologically based, severe mental disorder."

Overall, the 1-percent estimate is a good rule of thumb and includes early onset and late onset schizophrenia.

"By early onset we mean people who (were affected) early in life and aged with the disorder," explains Bartels. "Long-term studies of schizophrenia suggest that half the people with schizophrenia get significantly better with the passage of time. Some have clear resolution of their hallucinations, delusions and paranoia in late life while some continue to have psychotic symptoms into late life even though they are on medications."

An estimated 24 percent of people with schizophrenia get their first onset after the age of 45. "Dilip V. Jeste, MD, University of California, San Diego, pioneered the work in terms of identifying late onset schizophrenia and did find there are people who get psychotic illnesses in late life," shares Bartels. "Interestingly, people who get psychotic illnesses in late life tend to look quite different than people who have early onset, in part because they spent much of their lives being married, having jobs, etc. They have significant hallucinations and delusions, but the way they speak seems completely normal. People with early onset schizophrenia tend to have thought disorder and the way they process information is disorganized. The disorganization is the most crippling part of the illness."

Where early onset schizophrenia is evenly distributed between men and women, late onset schizophrenia affects more women and genetics aren't quite as involved.

"There tends to be a higher prevalence in hearing deficits; unusual things that make us think there is something different happening with late onset schizophrenia," says Bartels.

The Focus of Research

Research tends to focus on interventions and treatments and treatments have become more effective in the last decade.

"Combined with medications, we have gotten smarter with rehabilitation to support people in the community," says Bartels. "Evidence-based practices supported by research clearly are effective for people with schizophrenia and severe mental illness; however, resources in the community mental health system are getting gutted. States are having trouble with Medicaid funding and they are cutting mental health services across the country. The Medicare dilemma is twofold: if you have a major mental illness there is no pharmacy benefit and the insurance program does not have full parity for mental health relative to medical health. It is not adequately addressing or supporting the need."

People with depression, anxiety disorders and other mental health problems are more likely to seek help from primary care providers vs. specialty providers like geriatric psychiatrists.

"Several studies look at integrating mental health care services in the primary care doctor's office," shares Bartels. "I am part of the Prism study, which examines the outcomes and costs for randomized people to either see a master's level mental health clinician compared to giving them a referral to a specialty mental health clinic. Older people are very concerned about the stigma of mental health illnesses and they have problems with transportation and mobility. It makes sense to bring mental health and medical together and have there be a dialogue about optimal care."

Treatment of Mental Disorders

Treatment of mental disorders in older adults encompasses pharmacological interventions, electroconvulsive therapy and psychosocial interventions. While the pharmacological and psychosocial interventions used to treat mental health problems and specific disorders may be identical for older and younger adults, characteristics unique to older adults may be important considerations in treatment selection.

The special considerations in selecting appropriate medications for older people include physiological changes due to aging; increased vulnerability to side effects, such as tardive dyskinesia; the impact of polypharmacy; interactions with other comorbid disorders; and barriers to compliance. Changes may occur in the absorption, distribution, metabolism and excretion of psychotropic medications.

Pharmacodynamics, which refers to the drug's effect on its target organ, also can be altered in older individuals. It is often recommended that clinicians "start low and go slow" when prescribing new psychoactive medications for older adults. Efficacy is greatest and side effects are minimized when initial doses are small and the rate of increase is slow. Nevertheless, the medication should generally be titrated to the regular adult dose in order to obtain the full benefit. The potential pitfall is that, because of slower titration and the concomitant need for more frequent medical visits, there is less likelihood of older adults receiving an adequate dose and course of medication.

The increased risk of side effects is especially true for neuroleptic agents, which are widely prescribed as treatment for psychotic symptoms, agitation and behavioral symptoms. Neuroleptic side effects include sedation, anticholinergic toxicity (which can result in urinary retention, constipation, dry mouth, glaucoma and confusion), extrapyramidal symptoms (e.g., Parkinson's, akathisia and dystonia) and tardive dyskinesia.

In older adults, tardive dyskinesia typically entails abnormal movements of the tongue, lips and face. In a recent study of older outpatients treated with conventional neuroleptics the incidence of tardive dyskinesia after 12 months of neuroleptic treatment was 29 percent of the patients. At 24 and 36 months, the mean cumulative incidence was 50.1 percent and 63.1 percent, respectively. Unlike conventional neuroleptics, the newer atypical ones, such as clozapine, risperidone, olanzapine and quetiapine, apparently confer several advantages with respect to both efficacy and safety. These drugs are associated with a lower incidence of extrapyramidal symptoms than conventional neuroleptics are.

In addition to the effects of aging on pharmacokinetics and pharmacodynamics and the increased risk of side effects, older individuals with mental disorders also are more likely than other adults to be medicated with multiple compounds, both prescription and nonprescription (i.e., polypharmacy). Older adults (age 65 or older) fill an average of 13 prescriptions a year (for original or refill prescriptions), which is approximately three times the number filled by younger individuals. Polypharmacy greatly complicates effective treatment of mental disorders in older adults. Specifically, drug-drug interactions are of concern, both in terms of increasing side effects and decreasing efficacy of one or both compounds.

Source: Mental Health: A Report of the Surgeon General, www.surgeongeneral.gov

Legislative Alert

The Federal Community Mental Health Services Block Grant provides funds for state mental health programs and assists states in establishing, implementing or expanding an organized community-based system of care for adults with a serious mental illness and children with a serious emotional disturbance. States are required each year to report a state plan for comprehensive community mental health services.

One in five older adults has his/her quality of life seriously compromised by mental health needs yet is unlikely to take advantage of mental health services. Most states spend almost nothing on programs that treat the unique needs of older adults. Making older adult services a priority with a Federal Mental Health Block Grant will encourage states to develop programs for older adults.

Source: Mental Health and Aging Web site, www.mhaging.org

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